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A condition in which serum vitamin B12 is normal of elevated, yet and at the same time metabolic markers pr symptoms suggest that the subject is vitamin B12 deficient Such conditions represent "Paradoxical B12 deficiency" Metabolic analysis suggests that functional deficiency in either folate or vitamin B2 is the cause of paradoxical B12 deficiency Resolution of Paradoxical deficiency requires complete resolution of functional B2 or folate deficiency Paradoxical B12 deficiency is commonly seen in conditions such as Autism Chronic Fatigue Syndrome Hypothyroidism Various malignancies Long COVID All cause mortality Persons with Paradoxical B12 deficiency are more likely to die from COVID-19 The current dogma on vitamin B12 deficiency implies a direct link between levels of serum vitamin B12, and sufficiency

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The most common treatment is lifelong B12 intramuscular injections although small amounts of B12 can be absorbed without intrinsic factor